Address
Form of work
SalaryMedical Risk Consultant
Work Remotely in the United State
Primary Job Purpose
The Medical Risk Consultant collaborates with underwriters to proactively evaluate and price potential ongoing risks that will affect the loss ratio of a stop loss group. This position provides medical input on claim payment interpretations.
General Functions and Outcomes
- Assists the underwriting team in evaluating and pricing the risk of potential large claimants for all new groups and renewals.
- Reviews the costs associated with the risk and have a working knowledge of costs in the Blue Environment.
- Develop processes for risk analysis in coordination with underwriting.
- Assists with tracking of risk on high cost claimants.
- Assumes responsibility for maintaining clinical competency, for example attending pertinent medical conferences, workshops, and seminars relating to current medical practices, procedures and healthcare industry on at least an annual basics.
- Assumes accountability for the monitoring, quality assurance, or training of new staff, as assigned.
- Shares knowledge with colleagues that will enhance the performance of job functions.
- Provides input on medical interpretations and the setting of claim reserves.
- Assists with TPA/broker or other external visits.
Minimum Requirements
- Demonstrated competency to work in conjunction with the underwriters to come up with creative risk solutions.
- Demonstrated knowledge of medical technology and the related cost.
- Extensive knowledge of facility inpatient and outpatient coding and/or claim review, facility and benefit contracts, language and implications.
- Advanced knowledge of medical and surgical procedures and other healthcare practices required.
- Demonstrated understanding of standard office and business practices and desktop applications; excellent computer skills and proficiency working software programs (e.g., Microsoft Word and Excel, Outlook, and database query tools).
- Able to function efficiently in multiple claim systems.
- Demonstrated math aptitude, analytical ability, competent in performing complex and detailed work with high level of accuracy and independently without direct supervision.
- Strong communication skills; clear and succinct, both orally and in writing, with peers and colleagues, regarding complex and sensitive issues.
- Experience leading complex internal projects and initiatives impacting business operations and product decision making.
- Demonstrated research and documentation skills.
- Advanced knowledge of health plan cost containment strategies including medical management interventions, provider contracting methodologies, and benefit design alternatives.
- Demonstrated competency in analyzing cost of care based on highly individualized data.
- Demonstrated competency to interpret risk with varying factors that are individual and group specific.
- Strong knowledge of case management functions and the ability to be a resource to that team.
Normally to be proficient in the competencies listed above
The Medical Risk Consultant would have an Associate's or Bachelor's degree in health-related field and a current RN License with 5 years of experience in the health insurance or healthcare field in addition to 3 years of clinical experience.
Required Licenses, Certifications, Registration, Etc.
RN
Work Environment
No unusual working conditions.
The expected hiring range for a Medical Risk Consultant is $109,700.00 - $148,400.00 depending on skills, experience, education, and training; relevant licensure / certifications; performance history; and work location. The bonus target for this position is 18.75%. The current full salary range for this role is $103,000.00 to $168,000.00.
#LI-remote
Base pay is just part of the compensation package at Cambia that is supplemented with an exceptional 401(k) match, bonus opportunity and other benefits. In keeping with our Cause and vision, we offer comprehensive well-being programs and benefits, which we periodically update to stay current. Some highlights:
- medical, dental, and vision coverage for employees and their eligible family members
- annual employer contribution to a health savings account ($1,200 or $2,500 depending on medical coverage, prorated based on hire date)
- paid time off varying by role and tenure in addition to 10 company holidays
- up to a 6% company match on employee 401k contributions, with a potential discretionary contribution based on company performance (no vesting period)
- up to 12 weeks of paid parental time off (eligible day one of employment if within first 12 months following birth or adoption)
- one-time furniture and equipment allowance for employees working from home
- up to $225 in Amazon gift cards for participating in various well-being activities. for a complete list see ourExternal Total Rewardspage.
We are an Equal Opportunity and Affirmative Action employer dedicated to workforce diversity and a drug and tobacco-free workplace. All qualified applicants will receive consideration for employment without regard to race, color, national origin, religion, age, sex, sexual orientation, gender identity, disability, protected veteran status or any other status protected by law. A background check is required.
If you need accommodation for any part of the application process because of a medical condition or disability, please email
CambiaCareers@cambiahealth.com
. Information about how Cambia Health Solutions collects, uses, and discloses information is available in our Privacy Policy
. As a health care company, we are committed to the health of our communities and employees during the COVID-19 pandemic. Please review the policy on our Careers
site.
